brain/spinal injury

Question 1

Scenario Question:

Nurse Johnson has just started her shift in the neurology unit when she is notified about a new patient, David, who was involved in a motor vehicle collision resulting in a suspected traumatic brain injury (TBI) and possible spinal cord injury (SCI). David is currently unconscious and being transported to the hospital.

Upon arrival, Nurse Johnson must quickly and efficiently assess David’s condition and begin immediate intervention based on the established nursing framework for TBI and SCI management.

Given the information provided, which of the following initial steps should Nurse Johnson prioritize?

A) Nurse Johnson should immediately assess David’s Glasgow Coma Scale (GCS) score, secure his airway, and prepare for potential ICP monitoring, while also ensuring cervical spine stabilization to prevent further injury.

B) She should first order a pupillometer evaluation to assess for any pupil changes before moving forward with any other assessments or interventions, as this will provide instant diagnostic information about the severity of brain injury.

C) Considering potential intracranial bleeding, Nurse Johnson should skip initial assessments and immediately prepare David for a craniotomy with Burr Holes.

D) Focusing on potential SCI, Nurse Johnson should ignore TBI protocols and directly proceed to apply skeletal traction and a cervical collar without initial assessment.

Answer 1

This is a comprehensive breakdown of the relationships among key concepts in the management of traumatic brain injury (TBI) and spinal cord injury (SCI) from a nursing perspective. Let me align them for you:

Traumatic Brain Injury (TBI) and Spinal Cord Injury (SCI) - Relationships

1. Pathophysiology (TBI and SCI):
   
   • Cerebral contusion is a type of TBI where the brain is bruised, leading to symptoms like loss of consciousness, stupor, and confusion, with effects peaking after 18-36 hours.
   • Persistent localized pain could suggest a fracture, and specific findings like Battle’s sign, CSF otorrhea, or CSF rhinorrhea can indicate basal skull fractures.
   • Intracranial hemorrhage such as epidural or subdural hematoma has distinct characteristics and time courses, with epidural being an extreme emergency and subdural varying from acute to chronic.
   • For SCIs, the damage can be either a complete or incomplete lesion, which affects planning and intervention strategies.
2. Diagnostic (TBI):
   
   • Craniotomy with or without Burr Holes might be indicated based on the location and severity of the intracranial bleeding.
   • Health history focuses on the injury details, while baseline and ongoing assessments monitor changes in the patient’s neurologic status.
3. Signs & Symptoms and Diagnostic (TBI):
   
   • Instruments such as a pupillometer help assess pupil changes, an important diagnostic step to determine brain injury severity and prognosis.
   • The Glasgow Coma Scale is a tool used to assess the level of consciousness (LOC) in TBI patients.
4. Planning (TBI and SCI):
   
   • Goals include maintaining a patent airway, preventing secondary injury, cognitive function improvement, and preventing complications.
   • For SCIs, planning also encompasses autonomic function stabilization, including the management and prevention of autonomic dysreflexia.
5. Interventions (TBI):
   
   • Interventions include ongoing monitoring (particularly of LOC), airway maintenance, and preventing hypercapnia (excess carbon dioxide in the bloodstream).
   • Mannitol, an osmotic diuretic, may be used to reduce intracranial pressure (ICP).
6. SCI Management :
   
   • Emergency Management: Any traumatic crash or injury should lead to the assumption of SCI until ruled out; immediate stabilization is crucial.
   • Medical Management involves pharmacological approaches for various bodily functions affected, with considerations for temperature regulation, motor and respiratory function, and skin integrity.
   • Skeletal Traction and Cervical Collar management are part of the protocol for patients with potential SCI to prevent further damage during transport and immediate care.
7. SCI - Shock Variants:
   
   • Spinal Shock: Affecting muscles and function below the injury level.
   • Neurogenic Shock: Affecting the autonomic nervous system.
8. SCI - Nursing Process:
   
   • Assessment and diagnosis of potential issues such as ineffective breathing patterns, impaired mobility, disturbed sensory perception, and the risk of complications like skin integrity or urinary issues.
9. Autonomic Dysreflexia (SCI):
   
   • An acute emergency in SCI patients that occurs due to irritation below the level of injury and can trigger severe hypertension.
   • Nursing Interventions: Include lowering blood pressure, postural management, medication administration, assessing the cause, and eliminating the trigger.

In summary, the relationships outline a framework for understanding and responding to the complexities of TBI and SCI. This framework integrates assessment (both initial and ongoing), diagnosis, planning with clear objectives (emergency and long-term), intervention (acute emergency management and surgical options), and nursing interventions (ongoing care, education, and rehabilitation assistance). Each aspect is crucial for the comprehensive care and recovery of patients with TBI and SCI.

Correct Answer Justification:

The correct answer is:

A) Nurse Johnson should immediately assess David’s Glasgow Coma Scale (GCS) score, secure his airway, and prepare for potential ICP monitoring, while also ensuring cervical spine stabilization to prevent further injury.

Justification for Choice A:

Initial assessment including the Glasgow Coma Scale and securing the airway are immediate priorities in a patient who is unconscious following trauma. Additionally, preventing secondary injury is a major goal in early management. Stabilizing the cervical spine is critical to prevent SCI and maintains alignment until a definitive assessment can be done.

Justification for Rejecting Other Choices:

• Choice B emphasizes the use of a pupillometer which, while important, is not the immediate priority over airway management, GCS assessment, and cervical spine stabilization in an unconscious trauma patient.
• Choice C suggests an invasive procedure without prior assessment and confirmation of necessity, which is not appropriate without adequate diagnostic information.
• Choice D focuses solely on SCI management and disregards TBI protocols, while initial trauma care must address both potential TBIs and SCIs until further assessment can delineate the injuries.

Question 2

Scenario Question:

During a busy night shift in the intensive care unit (ICU), Nurse Johnson is alerted to the rapid transfer of a patient from the emergency department. Mark, a 32-year-old construction worker, has fallen from scaffolding and sustained a significant head injury accompanied by neurological deficits that suggest a spinal cord injury (SCI). He is intubated, sedated, and has a Glasgow Coma Scale (GCS) score of 8.

As Mark arrives, the primary goals are to stabilize his condition and prevent further neurological deterioration. Nurse Johnson must prioritize her actions from the moment Mark’s stretcher wheels into the ICU.

Which of the following actions should Nurse Johnson prioritize first?

A) Nurse Johnson should commence continuous ICP monitoring, administer mannitol to reduce cerebral edema, and assess Mark’s spine with imaging studies to evaluate the extent of any potential SCIs.

B) She should immediately perform a full motor and sensory neurological assessment to determine the completeness of the suspected SCI, potentially reposition Mark to relieve pressure points and improve circulation.

C) Prioritize confirming the stability of the cervical spine with imaging before proceeding with any further intervention to ensure no additional harm is done to Mark during his ICU stay.

D) Focusing on potential complications of TBI, Nurse Johnson should check for signs of Battle’s sign, CSF otorrhea and rhinorrhea, and prepare for possible surgical intervention such as a craniotomy.

Answer 2

Correct Answer Justification:

The correct answer is:

C) Prioritize confirming the stability of the cervical spine with imaging before proceeding with any further intervention to ensure no additional harm is done to Mark during his ICU stay.

Justification for Choice C:

The stability of the cervical spine is crucial for a patient who has sustained a head injury and exhibits neurological deficits. Securing the spine is a top priority to prevent exacerbating any SCI that may be present. Further assessments and interventions can proceed after ensuring the spine is protected.

Justification for Rejecting Other Choices:

• Choice A is important but does not take precedence over spinal stabilization, as movement or procedures could worsen a spine injury if it is unstable.
• Choice B is an important aspect of assessment, but again, without first ensuring spinal stabilization, there is a risk of causing further damage to the spinal cord.
• Choice D, while it entails important assessments for TBI, surgery preparation may be premature without the imaging and diagnosis necessary to guide such interventions. Spinal stabilization remains the first critical step before addressing TBI-related concerns in Mark’s state.

Question 3

Scenario Question:

Nurse Lee is on duty in a high-acuity rehabilitation unit when she receives a new patient, Carlos, a 26-year-old man who sustained a high-level spinal cord injury (SCI) two weeks ago after a diving accident. Carlos has been stabilized and transferred from the ICU for ongoing rehabilitation and monitoring. He is beginning to make progress with partial movement in his upper extremities, suggesting an incomplete lesion.

Carlos’s current treatment plan includes careful monitoring for autonomic dysreflexia, a potentially life-threatening condition he is at risk for due to the level of his injury. This morning, Carlos reports a pounding headache and a sudden increase in blood pressure is noted during routine monitoring.

Nurse Lee must act quickly to manage Carlos’s symptoms and prevent complications. Which of the following interventions should she prioritize?

A) Nurse Lee should immediately begin postural blood pressure lowering by elevating the head of the bed, checking for potential triggers such as a full bladder or bowel, and preparing to administer antihypertensive medication if needed.

B) With Carlos’s recent progress in motor function, Nurse Lee decides that engaging him in range-of-motion (ROM) exercises could be an effective distraction from the discomfort of his headache and could also assist in reducing his blood pressure.

C) Recognizing the risk for skin integrity due to immobility, Nurse Lee opts to focus on repositioning Carlos and applying anti-embolism stockings before addressing his headache and blood pressure concerns.

D) Given the acute nature of Carlos’s symptoms, Nurse Lee deems it best to immediately prepare Carlos for a diagnostic MRI to rule out other potential causes of his symptoms, like an intracranial hemorrhage, before proceeding with any interventions.

Answer 3

Correct Answer Justification:

The correct answer is:

A) Nurse Lee should immediately begin postural blood pressure lowering by elevating the head of the bed, checking for potential triggers such as a full bladder or bowel, and preparing to administer antihypertensive medication if needed.

Justification for Choice A:

This choice is the most appropriate and immediate intervention for autonomic dysreflexia, which is a medical emergency. Elevating the head of the bed can help lower blood pressure. Identifying and eliminating the cause, such as addressing bladder distention or bowel impaction, is a key part of the management. If these measures do not alleviate the symptoms, antihypertensive medications may be necessary to prevent complications like stroke.

Justification for Rejecting Other Choices: - Choice B does not appropriately address the emergent situation of autonomic dysreflexia. While range-of-motion (ROM) exercises are beneficial for rehabilitation and preventing complications associated with immobility, they are not the first-line intervention for autonomic dysreflexia, which requires prompt action to lower blood pressure and remove the triggering stimulus.

• Choice C focuses on long-term management goals such as skin integrity, which, although important in the overall care of a patient with SCI, does not address the immediate life-threatening symptoms of autonomic dysreflexia that Carlos is experiencing.
• Choice D, while prudent in some circumstances of unexplained neurological symptoms, is inappropriate as an initial response to autonomic dysreflexia. The priority is to address the high blood pressure and potential triggers directly associated with autonomic dysreflexia. Diagnostic imaging like MRI can be considered after the acute situation has been managed.

Hence, the immediate nursing interventions for autonomic dysreflexia, as described in choice A, are correct for Nurse Lee to prioritize in Carlos’s care.

Question 4

Scenario Question:

Nurse Martinez is caring for a 45-year-old male, Alex, in the neurosurgical unit who sustained a traumatic brain injury (TBI) from a fall. Alex is exhibiting signs of confusion and stupor and has persistent localized pain in the temporal region. Initial CT imaging is indicative of an epidural hematoma. His Glasgow Coma Scale (GCS) score is 13, and there’s a noted mid-stage pupillary reaction to light.

As Nurse Martinez reviews Alex’s chart and the latest imaging results, she anticipates the need for rapid intervention to address the suspected increase in intracranial pressure (ICP) secondary to his TBI.

Which of the following actions should she prioritize based on the management of traumatic brain injury as described in Chapter 68 of Hinkle & Cheever?

A) Nurse Martinez should immediately prepare Alex for a surgical craniotomy with Burr Holes to drain the epidural hematoma as it presents an extreme emergency with a risk of neurological deficit or respiratory arrest.

B) She should administer mannitol as prescribed to reduce cerebral edema and monitor respiratory function closely to prevent hypercapnia, which could worsen ICP.

C) Focus on reassessing the neurological status using the Glasgow Coma Scale and perform a pupillary assessment with a pupillometer, reporting any changes in size, shape, and reactivity to the healthcare provider (HCP).

D) Since Alex’s GCS is 13, Nurse Martinez should concentrate solely on secondary injury prevention strategies, such as maintenance of skin integrity and ensuring adequate nutritional status without more aggressive interventions at this stage.

Answer 4

Correct Answer Justification:

The correct answer is:

A) Nurse Martinez should immediately prepare Alex for a surgical craniotomy with Burr Holes to drain the epidural hematoma as it presents an extreme emergency with a risk of neurological deficit or respiratory arrest.

Justification for Choice A:

An epidural hematoma is a medical emergency requiring prompt surgical intervention to prevent life-threatening complications such as a rapid decline in neurological function or respiratory arrest. As Alex is showing signs of neurological compromise with a GCS of 13, confused state, and pupillary changes, immediate surgical planning to remove the hematoma takes priority to prevent further brain injury and potential fatal outcomes.

Justification for Rejecting Other Choices:

• Choice B is important to reduce cerebral edema; however, the imminent threat of an epidural hematoma requires surgical intervention first. Mannitol administration would happen concurrently or post-operatively as part of the ongoing treatment and management, not as the initial step in the presence of an acute epidural hematoma.
• Choice C fails to recognize the urgency of surgical intervention which should not be delayed by further assessments when an epidural hematoma has been diagnosed. While assessment is important, it should not supersede life-saving surgical intervention.
• Choice D suggests focusing on prevention of secondary injury; however, given the immediate life-threatening situation presented by the epidural hematoma, this is not the appropriate primary focus at this moment. Maintaining skin integrity and nutritional status are important aspects of ongoing care but are secondary to acute, emergent surgical needs.

Therefore, in this scenario, direct preparation for emergency surgery to address the epidural hematoma is the most critical and immediate action for Nurse Martinez to take.